Where to Place the Needles and for How Long?

Anthony Campbell

Revised 3 April 2018

This is the text of a talk given to a meeting of the British Medical
Acupuncture Society in 1999 (Acupunct Med 1999;17:2 113-117). It describes how I
thought about acupuncture at the time and it still mostly reflects my present
understanding, but naturally my view has evolved in the intervening decades
(I'd be worried if it hadn't!). In particular, I no longer use the Acupuncture
Treatment Area (ATA) terminology which I described in the original article and I
have therefore omitted it here. My current approach, which I now use in
teaching, is explained in my new textbook All You Need to Know about
Acupuncture.

Introduction

I shall talk about two aspects of using needle: site and duration. Both are
important but I shall spend most of the time on choosing the site since
this is where we find most variability in recommendations.

Where to needle?

Newcomers to acupuncture generally spend a lot of time asking where they
should place the needles. They often yearn for firm instructions about
this; they want to be told that in disorder A you should put the needles in
points x, y, and z, while in disorder B you should put them in points p, q,
and r, and that provided you do this you should get the hoped-for results.
There are numerous "cook books" available which purport to give this
information. When the beginner attends an introductory acupuncture course
he or she may get the impression that there is a a firmly established body
of rather arcane knowledge which must be gradually acquired, so that
becoming an expert acupuncturist is partly a matter of learning more and
more acupuncture points with their specific properties and effects.

As time goes by, however, the aspiring acupuncturist is likely to find that
this rather simplistic view of the matter doesn't correspond to what
actually obtains. Different teachers of acupuncture have quite divergent
ideas about how to choose which points to needle, as well as about the
duration and intensity of needling and other matters. This can create a
certain amount of confusion in the mind of the student.

Ideally, this should not happen. If there existed a body of
well-established and generally accepted theory about acupuncture, clear
implications for treatment would follow. Unfortunately, that is not the
case at present. It is still possible for skeptics to maintain that
acupuncture doesn't work at all except as a powerful placebo, and there is
notoriously little valid scientific research to place against such views.
Certainly there is almost nothing to show that any one method of practising
acupuncture is indubitably better than the rest. Indeed, most relatively
good-quality acupuncture trials seem to show a maximum response rate of
about 70 per cent, no matter which treatment method is used; this tends to
suggest that it may not make a great deal of difference in practice which
of them you choose to adopt.

What I should like to do here is to review the main methods of choosing
where to needle and then to propose a composite view which, I suggest,
represents a reasonably satisfactory compromise among all of them.

Possible methods of selecting needling sites

1. Traditional Chinese Medicine (TCM)

Acupuncture, of course, originated in China. (Actually, even this seemingly
uncontroversial statement may need to be modified; recent press reports
suggest that the "ice man" whose 5000-years-old body was recently
discovered in the Tyrolean Alps may have been receiving acupuncture for
backache; if this is correct the origins of acupuncture may be even older
than we thought but may not be exclusively Chinese.) TCM theory postulates
the existence of numerous acupuncture points with specific effects. If this
is correct, it follows that becoming a good acupuncturist must depend,
among other things, on learning the properties of a large number of points.
However, the evidence for point specificity is thin. Probably the
best-supported claim is for the anti-nausea properties of PC 6. More
recently research has appeared which seems to show that BL 67 can correct
fetal breech presentations (though this trial used moxibustion rather than
acupuncture). SP 6 does seem, on clinical grounds, to have some relation to
the pelvic organs in women, though good research evidence is lacking here.
Still, these are only three points out of some 360-odd described in the TCM
literature: hardly enough to erect a complete system of treatment. And even
the specificity of these seemingly well-established points is uncertain,
given the notorious difficulty of devising suitable control procedures in
acupuncture. At least some acupuncturists who started by practising in the
traditional way have been led, by their experience, to disbelieve in the
existence of acupuncture points as generally conceived. (Mann F.
Reinventing acupuncture)

2. Neo-TCM

I use the expression "neo-TCM" to refer to a rather heterogeneous
collection of treatments that have some kind of affinity with the
traditional system but have departed from it in various ways. Examples of
this include Ryodoraku, auriculotherapy, and scalp acupuncture. They
generally retain the concept of "points" in some form and may also use a
modified version of traditional pulse diagnosis; this is true, for example,
of auriculotherapy. All these systems suffer from the same drawback as TCM;
that is, they are largely unsupported by good scientific trials of their
efficacy and basic assumptions.

The remaining methods of choosing where to needle are non-traditional; that
is, they are attempts to reinterpret the basis of acupuncture in line with
modern ideas of anatomy and physiology. In principle, they ought to be able
to provide acupuncture students with ways of choosing where to needle that
are easier to accommodate within a scientific world view than that offered
by TCM, and to quite a large extent this is the case; however, the danger
is that by basing themselves too firmly on rather speculative theoretical
foundations they may become too restrictive.

3. Segmental acupuncture

This depends on the idea that the phenomena of acupuncture can be explained
in terms of the segmental representation of the body. Hence we have
treatment based on charts of dermatomes, myotomes, sclerotomes and
viscerotomes. The idea is intuitively appealing to an acupuncture modernist
who wants to rationalize the procedure, but at the practical level it can
be rather difficult to apply. One problem is that the segmental arrangement
of the body itself, although undoubtedly correct in a general way, is not
so fixed and clear-cut as the diagrams in textbooks might suggest. Another
is that when segmental theory is applied to acupuncture a certain aura of
vagueness and lack of precision begins to appear. Thus, treatment may
consist in needling a local point at the site of pain, a distant point in
the disturbed dermatome, myotome, or sclerotome. a point in a dermatome,
myotome, or sclerotome related to an affected organ, a point in a related
segment, or a point in an unrelated segment with a separate problem that is
acting as an aggravating factor. (Bekkering R, van Bussel R. Segmental
acupuncture, in Medical Acupuncture.) The student could be forgiven for
concluding that almost any combination of treatment points could
legitimately be described as coming under the rubric of segmental
acupuncture.

4. Trigger point acupuncture

Some acupuncture modernists make use of muscle trigger points (TPs) almost
exclusively. These are areas that are painful when pressed and from which
pain may radiate to distant sites. TPs may be found at muscle insertion
sites, in the free borders of muscles, and also sometimes in their bellies,
especially near their motor points. They may also be found in palpable taut
bands in muscles and in fibrositic nodules. The presence of these TPs gives
rise to what has been called the myofascial pain syndrome (to be
distinguished from fibromyalgia, which generally does not respond well to
acupuncture.) Studies have compared the distribution of known TPs with
classic acupuncture points; there is a good deal of overlapping although
the two are not identical.

5. Gunn's radiculopathy approach

Gunn has put forward an interpretation of acupuncture based on the
hypothesis that all the disorders amenable to acupuncture are due to
"radiculopathy". The theory holds that a peripheral nerve may appear
normal and may continue to function, yet may cause a condition of
"supersensitivity" in which the structures supplied by the nerve behave
abnormally. Spondylosis is said to be the commonest cause of
radiculopathy, and striated muscle is the structure most strongly
affected by the disorder; the muscle in question becomes contracted,
painful, and afflicted by trigger points. Gunn maintains that
acupuncture points are nearly always situated close to known
neuroanatomic entities, such as muscle motor points or musculotendinous
junctions. There are usually palpable muscle bands (trigger points) that
are tender to digital pressure. These tend to be distributed in a
segmental or myotomal pattern, in muscles supplied by both anterior and
posterior primary rami. Needling these bands causes the signs and
symptoms of radiculopathy to disappear.

Is there common ground?

If we look at the three "modernist" approaches to point selection that I
have summarized above, we see that there is a fair amount of common
ground among them. For example, the segmental theme reappears in Gunn's
radiculopathy, as does the idea of TPs. There is also common ground with
TCM, for at least some of the traditional acupuncture points could be
reinterpreted as TPs. So should we perhaps try to amalgamate these views
to provide a comprehensive "modernist" method of choosing where to
needle? Below I propose a method of doing this, which I believe makes
room for certain facts and observations which are otherwise difficult to
accommodate.

What is missed out?

Anyone who has read a fair amount of material about the background of
acupuncture will realize that the theories underlying the above
non-traditional approaches to acupuncture, while they may be partially
correct, are unlikely to be the whole story. For example, there is a lot of
evidence to suggest that the midbrain periaqueductal grey plays an
important role in pain transmission and perception, as does projection from
the prefrontal cortex through the thalamus. (Bowsher D. Mechanisms of
acupuncture, in Medical Acupuncture). There is also the phenomenon of
diffuse noxious inhibitory control (DNIC). This seems to be due to
A-delta-generated information transmitted to the subnucleus reticularis
dorsalis in the caudal medulla, which projects downward through the
dorsolateral funiculus to the dorsal horn of the spinal cord at all levels;
it can be activated by needle stimulation at non-acupuncture as well as
acupuncture points. These observations suggest that theories about
acupuncture based on putative changes in the muscles and peripheral nerves
are not a wholly reliable guide to choice of needling sites.

At a practical level, Mann has contributed the use of periosteal needle
stimulation as an additional acupuncture modality, and has also drawn
attention to the existence of a subgroup of people ("strong reactors")
who respond particularly well to acupuncture. He has also advocated the
use of minimal stimulation ("micro-acupuncture") for some patients; a
number of other medical acupuncturists have independently arrived at the
same way of practising. In his most recent acupuncture book,
Reinventing Acupuncture, Mann declares his disbelief in acupuncture
points as conventionally understood. However, he avoids putting forward
a theory of his own about how acupuncture works, since he thinks this
would be premature. I believe he is right to be cautious.

A theory-neutral way of practising acupuncture?

It seems to me that a great deal of what is written about acupuncture from
the practical standpoint is over-prescriptive. In other words, it's not too
difficult to say that someone is right, but hard to say that they are wrong
(safety questions aside). The following clinical observations seem to me to be
important.

In some people, and for some disorders, it makes comparatively
little difference where the needles are placed. (The DNIC
phenomenon partly explains this although its effects are
short-lasting).

There appears to be a "generalized stimulation" effect, whereby
a patient's sense of wellbeing can be improved and various
disorders influenced by needling. Like DNIC, this can be
non-specific; it can result from inserting a needle almost
anywhere, although certain sites, e.g. LR3, seem to be especially
effective in this respect.

In other cases needling needs to be more or less specific, but the
area of effective needling is very variable; it may be quite large
(i.e. several centimetres in diameter or even more). TP acupuncture
is sometimes of this nature, although at other times it seems to be
necessary to needle the TP very accurately.

It is sometimes possible to get a strong therapeutic effect from
sites which are not noticeably tender to pressure. It is therefore
incorrect to say that acupuncture is synonymous with the treatment
of TPs.

Periosteal needling (possibly a form of sclerotomal segmental
acupuncture) is effective for joint problems.

Needling or otherwise stimulating certain areas of the body will
characteristically give rise to radiation to other areas. This
phenomenon can be used therapeutically to influence disorders in
those secondary areas.

Minimalist acupuncture ("micro-acupuncture"—Mann) is
surprisingly effective in some patients and indeed is at times more
effective than "standard" acupuncture.

How long to needle?

This is an easier question to answer than where to needle, although as
usual we encounter a variety of advice. Most traditional acupuncturists
leave needles in situ for at least 20 minutes, often with intermittent
manual stimulation. Non-traditional practitioners may do something similar
but many prefer shorter periods of needling; electrical stimulation may or
may not be used. At the extreme this becomes minimalist (micro)
acupuncture, in which the needles are inserted for only a few seconds, but
a more common practice is to leave the needles in for one or two minutes.

Beginners in acupuncture naturally find it difficult to believe that very
brief insertion of needles can have much effect, but experience shows that
it does. This is probably explained by the rapidity with which the nervous
system habituates to a new stimulus.

There are undoubtedly some patients who will only respond clinically to
brief insertion; more prolonged needling, paradoxically, does nothing in
these cases. A number of people, me included, think that simply
inserting a needle and then leaving it without any sort of stimulation,
manual or electrical, for many minutes does little or nothing. On the
other hand, if the needles are stimulated repeatedly during prolonged
insertion there is a danger that some patients, especially those
classified as strong reactors, may suffer adverse reactions. When a
patient gives a history of feeling very ill after acupuncture it nearly
always emerges that the needles had been left in for a long time.

My own practice is to use brief stimulation in nearly all cases. This means
that needles are inserted for a maximum of about 2 minutes, often less.
Manual stimulation may or may not be used. In some patients the needling
can be much briefer than 2 minutes; in strong reactors and in children it
is enough to insert and withdraw the needle almost simultaneously, so that
total needling time is about a second. Periosteal needling is a strong form
of treatment and is often uncomfortable for the patient. It is therefore
always done briefly (1-5 seconds).

The main exception to this is patients who have become accustomed to
prolonged insertion and are convinced that this is essential. I think
myself that this is a psychological effect but if the patient is
convinced of it there is no point in entering into a dispute, so in such
a case I have used prolonged needling but without repeated stimulation.

In very rare cases I have used prolonged stimulation over several days,
with a stud needle stimulated electrically via a TENS pad. One patient, for
example, was a woman with repeated unexplained abdominal pain who responded
to stimulation at a point on the auricle (not corresponding to a Nogier
chart point); another was a woman with repeated severe vomiting who
responded to stimulation at PC 6. However, I think this should only be done
on in-patients because of the risk of infection.

Summary and conclusions

As already noted, dogmatic statements about these matters are out of place. I
therefore favour an eclectic method of choosing the sites to needle, based
mainly on typical patterns of sensation referral, together with the use of local
needling over painful areas in some cases. Some patients also respond
non-specifically to needling: a generalized stimulation response. As for
duration of needling, I favour using the least amount of stimulus that will
produce a response; this is nearly always less than one expects. This means that
needling should be brief (1-2 min or less in nearly all cases).